Payor, Provider, Patient: Healthcare by Consensus
Proceedings of the 12th Annual Symposium for Managed Care Professionals
Nancy Wilson Dickey, M.D.
Nancy Wilson Dickey, M.D.: "There's a lot of dissonance in the messages people get that contributes to their perceived need to change health care." We talk about the miracles and we take them for granted, but we don't often talk about the costs: developing the technology, the scientific research, or the care.
Nancy W. Dickey, M.D., is the immediate past president of the AMA, and sits on its executive committee. When the AMA selected Dickey to be its president, it marked a dramatic departure from the Marcus Welby-like mold that the nation's largest physician organization had favored. Dickey was the first woman to head the 294,000-member professional organization, where she has held a variety of leadership posts since 1977.
A board-certified family physician and a fellow of the American Academy of Family Physicians, Dickey received her M.D. and completed her residency at the University of Texas Medical School at Houston. In addition to maintaining an active family practice, Dickey is program director for the Brazos Valley Family Practice Program, associated with Texas A&M University in College Station, Texas.
I can't help but think that if the question before us is how to change the public's view of health care, the answer is simple: Let's change the health care system. Obviously, it's not quite that easy. But why should we change it? We have the best health care system in the world.
And yet, if you read our newspapers, we're not sure it's really the best system. Let me share some of the issues I think contribute to the challenge of developing the best system to go along with the best care that we could possibly have.
First, the United States has exceptionally good high-tech care. That, we don't want to change. But it certainly complicates the care-delivery process particularly for those who are attempting to pay for it as we attempt to satisfy what appears to be an unquenchable thirst for more and more care.
Second, a fair number of people believe that if they can just get to the right doctor, the right hospital, there is no problem in the United States that can't be fixed. Now, that comes about for a lot of reasons. The media like to tout the wonderful things we can do in health care, and frequently suggest that we can do almost anything.
You may recall the story about a young man who was working on a farm in Minnesota. He was by himself, had an accident with the machinery, and amputated both forearms. He got himself to the house, found the only touch-tone phone in the house, and dialed 911. Emergency care got there. They actually went down to the machinery and retrieved his arms. And [physicians were able to] reattach both.
What a story! It confirms what Americans believe: If I could get to the right doctor, there's no disaster we can't fix. That creates a problem: We can't cure everything.
Another issue: The United States health care system, its doctors, hospitals, pharmaceutical companies, and insurers are greedy. That message is reinforced, whether it's talk about greedy doctors, or about all of those terrible bureaucratic hurdles to keep me from doing things to patients that don't need to be done. And I return the favor by saying, "You know, it's just those greedy insurers. They're driven by the almighty dollar." And so when anybody, whether it's a pharmacist, a doctor, a nurse manager, or whoever, gives us some information, Americans wonder if they can trust it: I wonder what motivated that particular recommendation?
Here's another: I pay too much for my insurance, despite the fact that Americans pay very little compared to the amount [of health care dollars spent] per person. It hasn't helped, of course, that as the cost of care has been the focus, we have [increased] out-of-pocket costs or asked them to pick up a share of the premium.
It's in the midst of those not-exactly-collegial philosophies that your question about how to change the public's view of health care is both timely and appropriate.
What's contributed to this? First, an extraordinary half century of advances in health care. Think about what we've done in medicine in the United States in the last half century. Though we have only 6 percent of the world's physicians, the United States has over half of the Nobel prizes in medicine and physiology.
This country pushes the envelope all the time. We have eliminated entire diseases, such as smallpox, from the world, not just the United States. Other diseases, such as polio, have virtually disappeared from the United States, and we're working on getting rid of them in the rest of the world.
We have devised and virtually perfected the concept of transplantation. If you wear out an organ, no problem we'll give you a new one. We have seen remarkable advances in oncology, so that children with leukemia and mothers with breast cancer not only dare to hope, but have a reasonable bet that they can be cured.
HIV was once an 18-month death sentence if you were lucky. Today, I tell patients to work at controlling that disease, because they can look at years of productive life as opposed to planning their funeral the day they get the diagnosis.
We talk about the miracles and we take them for granted, but we don't often talk about the costs: developing the technology, the scientific research, or the care.
And that has helped create part of the perception problem in health care. In fact, over the last 50 years that same 50 years where medicine was developing this extraordinary array of possibilities we have gradually moved into a system of first-dollar coverage.
First-dollar coverage has insulated people from the cost of care, so they don't have to care about the cost of the transplant or even the medication that will go with that for a lifetime. And that combination of insulating people from the cost and stacking the shelves with a fabulous array of medical possibilities has led to some dissonance in our public that creates the problems in today's health care system.
This last decade has enhanced the tension. In the 1980s, the people who paid for care determined that cost had to be dealt with. The market began to change. Managed care became the byword. Saving money became the mantra, and it was simply presumed that quality would be there.
Costs did ameliorate or at least, they flattened the rate of rise for a time. In fact in California, premium rates actually rolled back a little. And they did so with some efficiencies carving some fat out of the system, putting some controls on decision making. Now we are beginning to see those flattened curves begin to rise again, and depending on where you are in the country, employers are faced with 5-, 7-, 10-, even 12- and 15-percent increases in premiums.
Some of the vehicles for cost saving were unacceptable to doctors, patients, or the public. In fact, the anger and frustration directed at the bureaucracy called managed care diverted virtually everyone from looking at some of the good things that were going on in managed care.
For example, managed care has moved medicine forward immensely in terms of measurement and evaluation. If you ask me whether immunization is good, I would say, "Absolutely, of course it is" It's one of the most cost-effective things we do. And if you ask me how many of my patients are appropriately immunized, I would say, "Why, most of them." But if you actually pull out doctors' charts, it turns out that some offices have 37-percent appropriate immunization, some 45 percent, and some really great ones get up to 62 percent.
Nobody has to tell us those aren't good numbers. But nobody had demanded that we pull out our charts and actually put a number to what our perception of our performance was. That's a good thing, as uncomfortable as it might be.
Managed care improved the integration of care. It recognized that some of the fat in our system was that both patients and physicians tended to use a lot more of the system than perhaps they needed. Patients had different doctors rather than a single physician when it was most appropriate. Because no one doctor knew the whole litany, there was no one to say, "This drug is offsetting that drug," or "You are taking two or three drugs that, theoretically, are all doing the same thing."
Nobody was listening to the good things managed care did, because they were angry and frustrated at the imposition of controls on their decision making.
People were fixated on seeking approval of experts. They were angry about having to call a clerk. They were distracted by awful tales of babies being diverted from one hospital to another and having complications. And that anger, I think, continues.
Well, that's where we are. A system that can deliver extraordinary things but maybe not as much as the public thinks. A system whose costs probably are going to continue to go up as some of this fabulous technology comes about. But a system that has insulated the users from knowing the cost.
Then how do we go about changing the system or the perspective?
First, we need to create an atmosphere where we appear to have a common goal, where the patient truly is at the center of our decision making. It sounds good from up here, but I worry sometimes that it isn't evident in what we do from day to day.
We need to discourage the kind of public finger pointing that destroys public confidence in us. As long as insurance companies point fingers and scream everything from "fraud" to "greed" to "ignorance," and physicians, in turn, point back and scream, "self-serving profiteers," how are we going to change patients' perception of the health care delivery system?
I believe that most of us in health care really do what we do because it's good for patients, that we want to provide better health care and improve outcomes, and find ways to do it in a cost-effective manner. But as long as we do battle, particularly public battle, patients will continue to see health care as a money machine for us. And they will then be encouraged to squeeze whatever is good for them out of the system, because they don't trust any of us to provide it for them.
Second, we need to find a mechanism to get patients more involved in decisions that affect them. As long as they are insulated from the cost of care, they will demand a great deal more maybe everything. Someone will have to be the bad guy who says, "You can't have that. I'll give you this cheaper alternative."
If we don't find ways for them to select affordable alternatives, there will continue to be a perception of having been done wrong by somebody in the system.
Americans like to be able to choose what they want. So if the only way to get to cost-effective decision making is by somebody the system, the government, or somebody forcing choices on patients, we are likely to have bad guys perceived.
There was a piece in the paper this morning: "A Brave New World of Medicine Expected in the Coming Millennium." Breeze through it. It's fascinating if you're a millionaire.
According to AMA President Tom Reardon, "Cures aren't really our final destination." Oh, really? He goes onto to talk about the fact we are going to have wheelchairs that go up and down stairs. I know what it costs when I write a script for a patient to get a wheelchair. What do you think the one that goes up and down stairs will cost? You can bet your booty my patients want that one not the one somebody has to push.
The article says that we're not going to do routine lab work anymore. We are just going to implant sensors under the skin, so we can have ongoing measures of insulin, glucose, liver function, and the like, if we're trying to treat somebody for a chronic disease.
If you're a diabetic or hypertensive or if you have pending osteoporosis, this has got to be an exciting story. But if you've got to pay for any of that care, this has got to be a little frightening.
So, we tell the press about all the new wonderful miracles that are coming: "Patients, look what we have to offer you." No one no one addresses the cost of care. We're going to need increasingly sophisticated ways to select needed treatments, and to find ways to select cost-effective treatment.
Insurance mechanisms that put patients at the table are going to be extraordinarily important. [Something that] makes my patients have to reach into their pockets not enough to become a barrier to getting needed care, but enough so that they're given an incentive to say, "What are the alternatives, and what do they cost?" They might have to tolerate some inconvenience and choose something that is less glitzy but actually does the same thing.
If patients are not at the table, then the only way to make those choices will be by regulation or by somebody refusing to provide the care.
I'd much rather have my patients say to me, "Doc, give me the prescription. If I'm not better in two days, I will come back for the chest X-ray and the blood count," because they understand that that's not only an extraordinarily clinically acceptable decision, but it's a cost-effective decision for them and for the system if you multiply it by the 1 million doctor-patient interactions that occur every day.
We also need to make measurable progress in providing meaningful quality information to decision makers, and that includes patients.
Physicians fear the data. We don't like report cards. We have been going through school since we were 4 years old. Most of us are tired of report cards. Besides, we are not sure we trust the people who are going to make the report cards. Maybe I take care of a tougher patient population, and it might show fewer good outcomes. Maybe, when you look at my numbers, I will find out that I'm not as good a doctor as I thought I was. It was a little embarrassing to discover what our immunization rates were. Nonetheless, physicians need to get over that and help develop meaningful report cards.
We need vehicles to measure how plans are working: what impact their cost strategies have not just on the cost of the premium, but also on [clinical] outcomes. We need to ask some questions besides cost and infection rates. We need to ask, "How many of your patients stay in the plan long enough to actually develop continuity of care?" My guess is that would be embarrassing to an awful lot of plans.
Maybe employers need data, as long as they're going to continue to drive the system. And if we're going to allow patients to make choices, then we need to give them information, too, to help them make choices. Good information.
The National Committee for Quality Assurance discovered that there is not much interest in things like HEDIS, because the numbers simply don't dig down deep enough to really differentiate plans.
We need things like NCQA; we just need to say, "Hey, we want you to go one more level. Don't give us a superficial grade. Actually read it. See whether the grammar and the punctuation and the thoughts in it are any good."
As we begin any campaign to educate the public about the potential benefits of managed care, we're going to have to push the proverbial boulder uphill, if you will, against this decade of teaching the public not to trust any source of information.
I rode in with a cab driver last night, and when he found out I was a physician, he said he had just gone to the doctor. I said, "Well, how do you like your doctor?"
"Oh, there's a different one every year," he said. "I just assume the HMO picks good doctors."
That's interesting. And I hope for his sake it does. But continuity of care has lost out. And some of the concepts of managing disease and managing care have lost out to cost-effectiveness issues. In fact, I often tell patients that they ought to spend at least as much time picking their primary physicians as they do their automobiles. I don't know anybody who walks into the first dealer they go to and says, "I'll just take that one," without talking about price, performance, and service.
We don't do that with our physicians. We look in the Yellow Pages, we wait until we get sick and go to the emergency room, or, these days, we wait until we get sick and figure out who somebody assigned us to see.
Dickey: We need to discourage the kind of finger pointing that destroys public confidence in the health care system. Insurance mechanisms that put patients at the table are going to be extraordinarily important.
My plea often falls on deaf ears, but I think that we should give patients incentives to know how systems work and where some of the cost savings are. And that while it's important for me to understand who my patients are, it's extraordinarily important for my patients to know who I am. Because if they don't trust my recommendations, I would encourage them to find another physician.
We need to balance that message with the immense challenge of how to figure out what to do with all this extraordinary technology.
And we need to attempt to move from the financial to the medical perspective of managed care. We need our patients to understand that managing their diseases means trying to make sure they spend as little time and money on dealing with illness as possible, so they have most of their time and money to deal with living.
These goals, if accomplished, would enhance public perception of health care.
DICKEY: People need to know the cost of the decision-making power they desire
Psychiatrists have said for years that if people don't pay for a little bit of the care, then it has no value. I'm not sure that I would go that far. But, it's important for patients to be involved in cost decisions as much as in care decisions.
Let me share some examples:
It's not uncommon in my office during flu season for people to come in with a cough and a fever. I do an examination and say, "It looks to me like you've got a little bit of pneumonia. I can get you a prescription, and if you're not better in a couple of days, come back and we'll do a blood count and a chest X-ray." And 100 percent of patients who have to pay a reasonable copayment or have to actually pay out of pocket for the visit say, "Great idea, and by the way, would you make it a $60 prescription, not a $200 prescription, for an antibiotic?"
But patients who have first-dollar coverage will almost always say to me, "I'm already here doc why don't you send me for the blood count and chest X-ray so I don't have to come back and sit in your waiting room a second time?" And my brain kind of says, "That's $300 I'm adding to the cost, and it probably doesn't change anything. But if they don't have to care how much it costs, what do they care about the $300? Their time in my waiting room is much more important to them than the cost of the chest X-ray and the blood count.
I talk about high cholesterol with patients, and the first thing we do is look at diet. Over half of them say to me, "Can't you just write me a prescription? Then I don't have to change my eating habits. I could eat my half-pound of ice cream every night before I go to bed." That's the American way.
My husband is a high school football coach, and periodically I serve as the team doctor. And when a kid twists a knee out there on the field, it's always an interesting debate. If you send him for his $900 or $1100 MRI, immediately you will know how bad the damage is. On the other hand, if the examination is fairly benign, then in the vast majority of cases, if that kid just sits out a couple of weeks and lets that sprain heal, there's no need to spend the $900. Now, if he's a $3 million-a-year football player for a pro team and they want to spend the money on an MRI, that may be different. But my moms on that football team look at me and say, "Why don't you want an MRI on my kid's knee?" It doesn't cost her anything; her insurance will cover it. And I would say, "You folks help contribute to this."
While it's important for me to understand who my patients are, it's important for them to know who I am. If they don't trust my recommendations, I would encourage them to find another physician.
Payor, Provider, Patient: Healthcare by Consensus
Old Saying Appropriate For Current Environment
David Brennan, Senior Vice President, Commercialization and Portfolio Management, AstraZeneca Pharmaceuticals
Health Status, Health Maintenance, and Health Care in the 21st Century
Louis Sullivan, M.D. , President, Morehouse School of Medicine;
Secretary, U.S. Department of Health and Human Services, 1989–1993
Health Care Reform: Payor, Provider, Patient
Health Care Reform: The Consumer's Viewpoint
Changing the Public's Image of Managed Care
Nancy Wilson Dickey, M.D. , Immediate Past President and member, executive committee, AMA
Treating Diseases and Managing Cost
The Power of Perspective
John Cassis, President, the Cassis Group
The 12th Annual Symposium for Managed Care Professionals was held November 11–13, 1999 in Scottsdale, Arizona, and was sponsored by AstraZeneca.
The opinions expressed in this special supplement are those of the symposium participants, and do not necessarily reflect the views of the sponsor or the publisher, editor, or editorial board of Managed Care.
PHOTOGRAPHS BY DENNY COLLINS